To bribe or not to bribe – that is the question Romania’s newly qualified doctors cannot avoid.

Maria Barbu tried. She searched for work in the hinterland, hoping to escape the nexus of corruption and nepotism that furthers careers in the big cities.

But even in a small town of 8,000 people, the hospital manager wanted €5,000 to hire her. “We talked in his office and he bluntly told me the price,” she says.

Barbu stuck to her principles and broadened her search. Thousands of miles away, a hospital in the German city of Kassel offered her a job. She accepted, paying for the move with a €5,000 loan whose value matched the bribe she had avoided.

She drove to Germany with her husband in a dowdy Renault Clio that is now parked outside her house. Barbu jokes that it is the “least eco-friendly car” in Kassel. It still has a Romanian number plate.

In a living room personalised with a religious icon from back home, Barbu admits that her move was out of character. Her friends had never imagined that she would join the exodus of Romanians going abroad for work.

“I am not the type of person who goes on an adventure,” she says, serving soup in a traditional bowl. “I am fearful.”

However, she is glad she came to Germany, even if the grey north European skies took some getting used to. “I feel respected by my patients and by society,” Barbu says. “When I went for my documents, I felt I had some status as a doctor.”

Her colleagues in Romania are not held in such high esteem. The medical profession is widely seen as corrupt. Patients often bribe their doctors. Some even insist on doing so, hoping to assure themselves of the best possible care. The venal doctor, often recorded in secret, has become a fixture of sting operations by tabloid papers and the TV news.

But behind the demonisation lies a less visible culture of corruption of which medical workers are also the victims.

At every step in their careers, Romania’s doctors and nurses must contend with a system that is accused of rewarding bribery and nepotism as readily as merit.

Of course, many of them hold out against this corruption. But many also pay money under-the-table in order to secure qualifications, employment and promotion.

The sums can be high, sometimes tens of thousands of euros. They are seemingly justified in a spluttering economy where medicine offers the rare promise of a stable if somewhat meagre wage. Moreover, the value of bribes paid can eventually be recovered through bribes received.

This story by the Balkan Investigative Reporting Network (BIRN) reveals how the insidious corruption among doctors creates a vicious circle, ensnaring their patients and successive generations of colleagues.

“All graduates, with a few lucky exceptions, are forced into a corrupt system,” says Vintila Mihailescu, a sociology professor at the National School of Political Science and Public Administration in Bucharest.

“The biggest guilt lies upstream,” he adds, explaining how doctors who pay for their jobs must accept bribes in order to recoup their investment.

Tarnished image

All Romanians are entitled to free medical treatment under a healthcare system that is funded by the state.

Resident doctors at the public hospitals earn around €200 per month. Specialists are paid €500. Even the higher wage would leave scant cash to spare after factoring in the rent for an apartment in the capital, Bucharest.

Many doctors supplement their income by working extra hours or moonlighting in the small but lucrative private healthcare sector.

Corruption in Serbian Hospitals

A civil society organisation, Serbia on the Move, recently established a text-messaging service for reporting corruption in the healthcare system.

Almost one-third of all the cases that it recorded concerned corruption in the recruitment process.

Doctors and nurses complained of being asked for money when they applied for work, according to Predrag Stojicic, the president of the board of Serbia on the Move.

He says the value of the bribes varied from €5,000 and €15,000, with the larger amounts attached to jobs at hospitals in big cities such as Belgrade, Novi Sad and Nis.

Stojicic blames part of the problem on the education system, saying it was producing more doctors than the country needed.

Many thousands of medical workers have also left Romania in the six years since their country entered the European Union. As motives, they cite the poor salary at home and the culture of corruption that it breeds.

“It is impossible to be a doctor in Romania without taking a bribe,” says Adina Derevenciuc, who moved to Germany after finishing medical school. “But I find that immoral… I refuse to work in a public hospital because it’s a sick system.”

Catalina Marioara, a Romanian medical student on an exchange programme in the German town of Griefswald, says she was startled by the contrast between the two countries. “I could never accept something from my patients. If I stayed in Romania, I would have to count on my parents’ help,” she says.

Relatively free to work in the EU, doctors from Romania have gravitated to France, Germany and the UK, where wages are substantially higher than back home.

Their skills, backed up by a readiness to do punishing night-shifts, have filled a critical shortage in hospitals across Western Europe.

But while their foreign profile grows, Romanian doctors struggle at home – poorly paid, ill-equipped and tarnished by tales of corruption.

Yet patients are sometimes willing participants in the bribe-ridden economy, pressing money upon doctors out of gratitude or fear. Doctors have even reported that the refusal to accept a bribe can distress patients, who interpret it as a sign that their condition cannot be cured.

“A doctor’s wages are low, too low,” says a woman in her thirties who did not want to be identified. She says she gave money to a maternity doctor who had helped her through a difficult birth.

Another woman, also speaking on condition of anonymity, says she kept trying to give an envelope of cash to a doctor who had treated her ectopic pregnancy.

“The doctor didn’t want the money. He avoided me so I went to his house after I was discharged. The envelope was crumpled because I had been carrying it with me in the hospital, in my dressing gown, or under my pillow,” she says. “I guess I did it as a ‘thank you’… and for my own peace of mind.”

Torn between the ethics and the exigencies of their profession, many doctors operate an informal code. They will accept bribes from patients but they do not ask for them.

Absence of whistleblowers

Like several quirks of modern life in Romania, the corruption in the medical system owes something to the intersection of centuries-old rural tradition with the recent decades of communism.

“The culture in Romania is that of the countryside, based on cultivating mutual trust,” says Mihailescu, the sociologist. “Patients mistrust institutions and feel the need to have a personal relationship with the doctor. This is why they pay bribes.”

Gheorghe Aldea, a retired doctor, says his colleagues in the communist era would receive gifts of gasoline, sugar, cigarettes and coffee. These items were hard to find on the market, and more prized than currency.

“Back then, you could not buy anything with money,” he says. “But you could receive oil or good meat without having to wait in line.”

Maria Barbu says doctors are better respected in Germany.

The seemingly innocuous barter economy of rural communism has evolved for the 21st century, with money taking the place of produce.

In a survey commissioned this year by the Romanian office of the Aspen Institute, an international non-profit organisation, more than 60 per cent of around 1,000 respondents said they had offered bribes to medical staff. In another recent survey, by the National School of Political Science and Public Administration in Bucharest, 59 per cent of respondents said that bribes were the only guarantee of decent hospital care.

The medical corruption cases that are reported by the press, or pursued by the law, typically involve patients who are unable or unwilling to pay bribes.

However, the corruption within the medical establishment – where many doctors pay their colleagues for employment and promotion – is rarely reported.

The sums and the stakes here are much higher, with careers and reputations hanging in the balance. The doctors who pay the bribes become complicit in a crime. They do not wish to destroy whatever advantage they have gained

Those who refuse to pay prefer not to make a formal complaint. They may lack evidence or they may not wish to be identified as troublemakers. Most of the doctors with first-hand experience of the culture of bribes spoke to BIRN on condition of anonymity. The names of the towns and cities they mentioned have also been withheld to protect their identity.

“I’ve heard rumours of corruption in the recruitment system but nobody told me about it face-to-face,” says Vasile Astarastoae, the president of the Doctors’ College, Romania’s medical watchdog.

He believes medical workers do not report bribery demands because they fear endangering their careers. “There are only a few jobs… and nobody else will hire me because they don’t trust me. They will say that I made it up,” he says, articulating the motives behind the silence.

Health minister Eugen Nicolaescu told BIRN he was unaware of corruption in the allocation of medical jobs. “I never heard such stories but I cannot argue against what some doctors claim to be true,” he says.

‘Pay up before summer’

The biggest bribes tend to be paid by newly qualified doctors in search of their first job. The money is pocketed by hospital administrators and senior doctors who are involved in the recruitment process.

The value of the bribe seems to be determined by demand. As more Romanians choose to live in large cities rather than depopulated rural areas, so too are doctors paying higher bribes to work at metropolitan hospitals rather than in smaller towns.

Daniela, a former paediatrician at a hospital in a large southern Romanian city, says she helped her husband look for work after he qualified as a doctor. She spoke to BIRN on condition of anonymity because she feared harming her prospects if identified.

Daniela says the couple’s colleagues advised them to make discreet inquiries about buying a job in the region. Their search uncovered a sliding scale, where the size of the bribe for getting hired seemed linked to the size of the town.

She says they were told that a doctor’s job in a nearby town of roughly 9,000 people would cost €15,000. Meanwhile, the same job in a city with a population of 105,000 would cost €20,000.

In one of the country’s largest cities, with a quarter of a million inhabitants, it would cost €30,000 to get hired by a hospital. “They told us we should pay up before the end of summer because there was a long list of applicants,” says Daniela.

The couple decided against giving bribes as the cost began approaching that of buying a new apartment. Daniela is convinced they did the right thing.

“If you pay, you start thinking of getting your money back. You wait for bribes,” she says. “This is how you lose your dignity as a doctor.”

Her husband eventually found a job at a hospital in France. Daniela joined him this autumn.

Where the value of the bribe tracks the size of the town, the population is effectively presented as a resource which doctors must pay to access. In this way, the corruption between doctors increases the likelihood that they will accept bribes from patients to recoup their investment.

Several doctors, speaking anonymously, confirmed that it was impossible to get hired in the larger towns or cities unless one paid a bribe or had good contacts.

The corruption is not limited to the recruitment of doctors. “There are only two ways to get a job here,” says a nurse at a small town in southern Romania. “You either pay for it or you know the right people.”

Thanks to an influential contact, the nurse was spared from paying a €2,000 bribe for the job.

‘No strategy’

The high demand for jobs in the larger towns and cities is in stark contrast to a shortage of medical staff in impoverished rural Romania – the places at the opposite end of the sliding scale. The disparity has persisted, even though doctors in the public health system are paid the same throughout the country.

“In small towns, you earn only your salary because people are poor,” says Stefan Stanculescu, the manager of a hospital in Bals, which has a population of 20,000. “Young doctors keep away from these hospitals.”

Romanian doctors abroad

Almost 2,500 doctors left Romania in 2012, according to the Doctors’ College, the country’s medical watchdog.

However, the total number of medics leaving Romania is likely to be higher, as this figure above does not the include the many people who migrate before fully qualifying as doctors.

Meanwhile, some 2,910 Romanian doctors were registered in Germany in 2012, according to the German Medical Association. The figure has doubled since 2009, when doctors first began leaving Romania in large numbers.

The German healthcare system is in the midst of a staffing crisis, caused in part by the migration of its medics to Norway, Denmark and Switzerland, where wages are higher. There were also approximately 600 Romanian doctors working in the UK in 2012, according to the Health and Social Care Information Centre. Again, the figure is double what it was in 2009.

Ioana Dumitru, the manager of a hospital in Filiasi, a town of 18,000 people, also says young doctors avoid working in impoverished areas because “they do not wish to rely only on their salaries”.

Of course, corruption is not the only factor behind the shortage of medical staff in rural areas. Honest doctors may avoid the countryside because a lack of modern equipment raises the risk of malpractice claims – not because the patients are poor. At the same time, they may be drawn to Bucharest because of better promotion opportunities, rather than its pool of wealthier patients.

Either way, the higher demand for jobs in the big cities is reflected in the value of the bribes demanded for them.

Many medical workers blame the healthcare system, believing that it creates more doctors than it can employ. The corruption in the job market, as well as the exodus of staff to western Europe, is seen as a product of this surfeit. Yet the shortage of doctors in some parts of the country complicates this picture.

To examine the claims of an over-supply, BIRN tried to compare the number of doctors hired by public hospitals in 2012 with the number who qualified. But over the course of four months’ inquiry, neither the health ministry, the national statistics agency nor the medical watchdog were able to say how many doctors had been recruited.

“The health ministry does not have a human resources strategy,” says Dumitru, the hospital manager from Filiasi. “They do not collect statistics that show how medicine has changed.”

Astarastoae, the head of the medical watchdog, says the health ministry had only recently begun taking account of his agency’s advice on how many hospital doctors were needed each year.

“The results will be visible after six or seven years,” he says. “Now, we have unemployed doctors with some specialisations and at the same time we lack others.”

The government rejects the criticisms, insisting that the number of doctors that qualified for hospital work matched the need. “We are thorough in deciding how many places to have each year at the residency exam,” says Nicolaescu, the health minister.

Pay to pass

Corruption is commonplace throughout the Romanian education system, and medical schools are no exception.

Eight of the 10 medical students interviewed by BIRN said they had “arranged” at least one exam – in other words, offered money or gifts to ensure better grades. All spoke on condition of anonymity.

The photocopied textbooks used by impoverished doctors in Romania contrast with the editions used in Germany.

The distinction between gifts and bribes can be blurred, typically when a group of students splits the cost of a purchase for an examiner.

“We bought expensive perfumes for the women… and whiskey for the men,” says a former doctor from Bucharest. He says he left medicine because he was uncomfortable with the corruption.

Some exam results must be paid for in cash. BIRN’s interviews with students suggests that the value of these bribes varies from €100 to €600, depending on the institution.

A student from a city in western Romania says she paid €100 to avoid having a tough exam. “If I refused to pay, the teacher would keep asking questions until there was one that I could not answer,” she says.

Several medical students from a city in southern Romania say they paid around €200 to buy completed theses from their tutors, which they then submitted as their own in a final exam.

As none were willing to be quoted by name or to take their case to the authorities, BIRN could not confirm their accounts.

However, the heads of both institutions where these students had enrolled were asked to respond to the broad allegations of corruption. Both denied the claims and defended the reputation of their staff.